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12 Characters
1 Uppercase letter
1 Lowercase letter
1 Number
1 Special character
Initial Affiliation Date
Affiliate Status
AccountId
PrimaryContactId
Docs are Current
TRUE
Dues Waived
TRUE
Affiliate Profile
Please verify and update the information below as necessary.
Fields marked with an "*" are mandatory.
Official Name of Affiliate
Year Established
Street Address
City
State
Zip Code
Phone
Number of Locations/Offices
Please upload** a list of locations with address and phone number
**Note: there is a 35 MB limit for the total size of uploaded files submitted on this form. If an error is received after submitting this form, please reduce the size of the total documents uploaded to under 35 MB and submit again.
Organization Information
Number of full-time staff
Number of part-time staff
States/Counties Served
Unduplicated count of persons (participant/clients/customers) served last year
Enter the % of persons served last year for each demographic (totaling 100%)
Hispanic, Latino or Spanish Origin
White
Black or African American
American Indian or Alaska Native
Asian
Native Hawaiian or Pacific Islander
Two or More Races
Organizational Budget
$0 - $100,000
$100,001 - $500,000
$500,001 - $1,000,000
$1,000,001 - $5,000,000
$5,000,001 - $10,000,000
$10,000,001+
Membership amount due
Based on organizational budget
Do you need an invoice?
Yes
No
Please upload** the last audited financial statements of all public and private funds received, or the last Form 990 submitted to the IRS
**Note: there is a 35 MB limit for the total size of uploaded files submitted on this form. If an error is received after submitting this form, please reduce the size of the total documents uploaded to under 35 MB and submit again.
Please upload** a list of the Board of Directors and Senior Management
**Note: there is a 35 MB limit for the total size of uploaded files submitted on this form. If an error is received after submitting this form, please reduce the size of the total documents uploaded to under 35 MB and submit again.
Programs Offered
If your Organization offers multiple Programs, click the "Add Another Program" button for each additional Program
ProgramId
Program Name
Target Population
Program Funding Source
Funding Amount
Program Status
Active
Planned
Completed
Cancelled
Primary Program Category
Advocacy
Counseling
Education
Emergency Assistance
Employment
Financial Stability
Food and Nutrition
Housing
Information & Referral
Legal
Medical Health
Mental Health
Seasonal Programs
Workforce Development
My program covers a secondary category
Yes
No
Secondary Program Category
Advocacy
Counseling
Education
Emergency Assistance
Employment
Financial Stability
Food and Nutrition
Housing
Information & Referral
Legal
Medical Health
Mental Health
Seasonal Programs
Workforce Development
Please add one or two sentences describing your program
Form Submitted By
First Name
Last Name
Title
Phone
Email
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